Monday, March 30, 2015

What Adds Value to Mental Health Care? Looking for Your input....

I need  your help.  This year at the American Psychiatric Association's annual meeting in Toronto, I will be talking on what adds 'value' to mental health care from the patient perspective.  It's a symposium, and the other speakers will be approaching the issue from the perspective of the insurance company, the hospital, employers, and looking at things like quantifiable measurements of success measured with standardized tools and how to recognize waste in the systems.  I won't be talking about standardized tools.

So I need input.  If you're a  health professional and you've never seen a psychiatrist as a patient, please don't answer.  I want to hear what people see as 'value in mental health care' straight from a patient's perspective.  

Some possible questions include those below, but please feel free to tell me what you value about your mental health care.

  •  I'd like to hear what experiences and outcomes make you feel like you've gotten your money's worth?    
  • Why do you go to treatment?
  • What are you looking to get from it?
  • Do you have specific goals that you'd like to see measured by objective criteria?
  • Have you ever seen a psychiatrist for treatment, gotten better from your disorder, and yet not valued the care? Why?
  • Do you like that insurers and providers are looking at what makes for good value, meaning the best outcomes for the lowest cost?
  • In short: what makes for a good experience with a psychiatrist?  You can also tell me what makes for a bad experience.
  • While I've got you here, do you value having your psychiatric chart in an electronic medical record?

If you don't want to comment here, please feel free to email me at shrinkrapblog at gmail dot com.  

Sunday, March 29, 2015

"Mental illness" is not the Endpoint Answer to Why Someone Commits Mass Murder

Over on Clinical Psychiatry News, I wrote a an article about still-unfolding story of the Germanwings co-pilot who deliberately crashed a plane into the French Alps, killing 150 people.  Please surf over to read Was Mental Illness a Factor is the Germanwings Crash.   I'll warn you that the facts aren't all in yet, so the article is purely speculative, and it's possible we will never know why this co-pilot decided to crash this plane into a mountain.  I also tell you that as a psychiatrist, I don't know why someone commits mass murder; I've had no experience with patients who kill, much less kill 149 other people, nor have any of my colleagues or mentors.

Tawnydog1 may be right in her tweet above, the New York Times already has a front page article calling for  screening for pilot mental health issues.   Since the event of pilots crashing their planes into mountains is extremely rare (1 in many millions) and the pilot was said to have had an eye problem, I'm wondering why they aren't calling for better screening for eye problems?  Really, we don't know anything yet: we've heard nothing about the stresses in this man's life, whether he was telling friends and family that he was having delusions, why he took time off from training, what his illnesses were, and how he dealt with anger.  

I'm going to go out on a limb here: people commit suicide for a number of reasons, one of them being a way to escape the unbearable pain of depression.  People kill for a number of reasons, one of them being because they are angry.  There are many mentally ill people in the world and there are many angry people in the world.  There are very few mass murderers.  We need to stop using "mental illness" as the endpoint to answer the question "Why?" when a mass murder happens.  Mental illness is not an explanation, and this may be a problem that is so rare that there will never be a reasonable response to this event other than to say that for any number of reasons, pilots should not be alone in the cockpit of a commercial passenger plane.

Saturday, March 28, 2015

Resilience: Two Sisters, Mental Illness, A Trust Fun and Quite the Ride

Resilience: Two Sisters and a Story of Mental Illness is a memoir written by Jessie Close with journalist/advocate Pete Earley, plus a few 'chime in' chapters written by Jessie's actress sister, Glenn Close.  

So let's start with family history.  It's a good place to start and we learn that the Close sisters come from a line of those who were rich, famous and colorful -- ancestors with names like E.F. Hutton and C.W. Post.  Not to mention great-uncle Seymour who thought he was a German spy then took hostages at gunpoint and had his chauffeur drive them home.  

Close describes a happy childhood living on her grandparents' estate in Greenwich while her father remained in Manhattan for his surgery residency.  Happy, until her parents joined the Moral Re-Armament or MRA, a religious cult.  From there, the family began to fracture.  First, it was just the parents who left and MRA nannies raised the children,  but then the family moved to MRA-run estates in New York, then Switzerland, and finally Jessie -- the designated problem child-- joined her parents in Africa.  She describes a lonely, chaotic childhood marred by anxiety and abandonment. 

From here I'll avoid plot spoilers and just tell you that what follows is a story of sex (and more sex), drugs, alcohol, as well as some rock & roll with much of the compulsive energy being explained by either mania or depression.  There are five marriages and three children, countless houses, cars, and dogs,  and a diagnosis of bipolar disorder along the way.  Jessie eventually lands in a place where she is more comfortable, balanced, and in control of her emotions and behavior. 

Psychic peace, in this case, comes at a price.  Recovery is not a smooth road for Jessie and in giving up her mood swings, my sense was that Jessie lost a part of herself.  So if you worried that this would be a placating story of how psychiatry is all good, rest assured that the author has her share of rare adverse reactions to psychotropic medications, not to mention a struggle with medication-induced weight gain which she minimizes.  In the end, she finds solace in her own company -- something she seemed to find unbearable before -- and decides that she needs to forsake romantic relationships.  These tradeoffs are those a person will  make only when their pain is unbearable.  

The bottom line on the memoir: two thumbs up.  The book is a quick read as Jessie Close pulls you on to her roller coaster ride of a life with severe, unremitting mood swings.   

Sunday, March 15, 2015

How Was Your Stay in a Psychiatric Hospital? -- Please Take My Survey: 5 quick questions

I'd like to tell you something.  The comments we get on this blog, especially lately,  talk about how horrible it is to be treated in a psych unit.  People say they would rather die then go back, they're infantilized, demeaned, and sometimes people describe frank abuse. They deem it comparable to rape and torture.  In my all-voluntary outpatient practice, I treat patients who sometimes get hospitalized and I make a point of asking people about their experiences.  People end up in psych hospitals during miserable periods in their lives, so it's never a happy issue, but unlike our blog commenters, my patients often say the  hospitalization was helpful, that people were kind to them, and that they left in a better state.  I don't work in the hospital and I generally have open and warm relationships with my outpatients -- who know I don't have anything to do with inpatient units -- so I'm thinking that perhaps they aren't lying out of fear of retribution if they are readmitted.

Let me add something else, the two biggest psych units near me are rated in the top ten in the country.  This may well be a skewed sample.  Few people go to state hospitals in Maryland for routine psych care-- the state hospitals are mostly for forensic patients and the state leases out short-term beds in community hospitals for the uninsured.  There are still a few long-term patients in the state hospitals, but not a lot.  And the chairman of my residency program made a point of asking every patient he interviewed if they were being treated well; The patient might be afraid to say they were treated meanly by a nurse, but the nurse would be even more afraid.  And please don't think that means that no one ever muttered an insensitive word to a patient or did the wrong thing, but I do think most patients there thought it fell short of torture.  In urban areas, many are looking for "three hots and a cot" and the hospital often fills that roll.  And some of the units attracted patients from all over the country who really, really wanted to be there for relief of their torment.

I'd like to know about your experience if you've ever been treated as an inpatient on a psych unit.  Will you take a quick survey for me?  And please -- this isn't science,  it's not validated -- but please just answer one time and one time only. And thank you so much!

Tuesday, March 10, 2015

Responding to the reaction to Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations? Polarized responses!

I saw the Mad in America article about my post on

Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations?

 I feel like it was misrepresentative to say that I wanted to give people cake and ice cream, as if that would undo the violation people might feel, especially after involuntary hospitalizations.  I was drawing on the example of what I saw in mental health court, that people who were incarcerated as criminals, then chose to participate in the MHC with all it's requirements (generally many: treatment, medications, often substance abuse treatment, requirements for day and residential programs) yet  end with a sense of being proud.  There is a graduation ceremony and they come if they want, invite their families, get certificates, take photos with the judges.  No one is forced to come, and the have fried chicken --which I somehow found humorous, but at the moment it's looking a lot better than the cake and pizza which are my favorite cheap foods.  Readers felt was demeaning and comparable to birthday party food for small children, and if I ever suggest food again for any event, it may be lobster.  I was trying to say that if something presumably traumatizing -- like getting arrested and labeled a criminal -- could later be turned to something that wasn't so shameful, maybe we should consider that sort of thing to help people feel less traumatized and shamed with hospitalization.  Without the mention of Mental Health Court's approach, it comes off as sounding like I want to feed people cake to make their pain go away and undo the violations they were subjected to, which I never meant.  I wanted just to ask if people felt that some validation of their distress would be helpful, and I think people like food with events. Or at least I like food with events.

I realize that some people who are involuntarily hospitalized are terribly traumatized, which is why I'm writing the book.  I don't think psychiatrists see that and I think if it were figured it into the equation, maybe less people would be involuntarily hospitalized (certainly, no one should be forcibly hospitalized for 'sadness' as one of the MIA commenters put it), other alternatives could be found, and more of an effort would be made to treat those where there are no options but involuntarily hospitalized with respect and kindness.  I thought the responses were polarizing, while commenters here and at Mad in America complained that I was lacking empathy, defensive, and just plain evil, Psychiatric Times deemed it one of the top 6 articles on psychiatry for the month! 

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at:

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at:

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at:
I stopped publishing the comments on my own blog, because as horrible as I hear people can be treated during involuntary stays, these feelings are not the same for everyone, and the comments because insistent, repetitive, and I don't think they left room for anyone to voice another opinion .  Some people get better and appreciate being in the hospital, some get better and still understandably resent it, and some are just terribly distressed for years.  When they get too extreme, I worry that people stop listening -- so while I know people feel terribly violated, I wonder if it wouldn't upset the victims of war torture, rape, and kidnapping, to have their experience compared to being in the hospital where people presumably are at least trying to help them?  And I think some people shut down when they hear someone compare treatment to torture -- there are those who will stop listening and discount their opinions. We live in a democracy, and I think folks might get more traction by talking with their legislators and proposing new laws; it's more powerful then blog comments.  And most psych hospitalizations are voluntary -- some coerced, but many people ask to be in the hospital, repeatedly, and find it helpful.

  I'm sorry this blog post turned out to be so polarizing.  No one has ever called me "evil" before.  And one commenter on my blog (unpublished) insisted psychiatrists just need to admit that their work is useless and never helps anyone and that I should become a gardener.  If it doesn't help you (and I mean the metaphorical 'you', not you personally!) then I can see why you might think that, but it seems unfair to insist that everyone has the exact same reaction to being hospitalized, or even being offered outpatient psychotherapy on a voluntary basis.   I'm also sorry that some of my comments came off as being defensive. Often I'm responding to blog comments quickly, between activities, and I often don't measure every word or consider how they might be construed from a variety of different perspectives.  Anyone who regularly reads my blog knows that my posts are done quickly and often with typos, I'm just stretched a bit too thin to do the proof-reading to catch them, and in a similar way, I sometimes reply to comments without thinking through every angle.  I also often have completely different views than the commenters.  And I admit that I do close up a bit when people insist that everyone experiences things the same exact same way that they do.  It leaves no room for people to be human.

Hundreds of thousands of people are involuntarily hospitalized each year.  While I won't be suggesting acknowledgment events in the book after the feedback I've gotten, I do wonder if just one of those hundreds of thousands of people might like someone to notice how painful their experience was and how hard they worked to get better, and perhaps be offered the chance to have their kids come have a piece of pizza with them when they were ready to go home. 

I am well aware that offering someone a "party" or a piece of cake doesn't make the bad of it go away and I never intended that.  There are some people who come in very sick and very psychotic, and who feel a lot better.  And by the 'exit interview' I was thinking some about the comparison to being raped -- -what could be worse than being raped and having someone tell you it didn't happen or wasn't that bad?  Might it help to be heard and have your violation acknowledged?  I hear that some people feel that wouldn't be safe and that if they were ever admitted again, they could be the subject of retribution.  I never meant for either an exit interview or a the offer of an acknowledgement meeting to be something that is forced, simply offered.  Sometimes it seems our commenters pit the patient as always the sane one -- as though people can never be sick or psychotic, or dangerous, or violent-- and the staff as purposely sadistic.  Patients can be sick, and there are bad people in all fields And believe me, I feel anyone who is intentionally cruel should be fired. 

Please feel free to post this in the comment for me on Mad In America.  Commenting here will be closed for a bit.  

Tuesday, March 03, 2015

Big Girls Don't Cry. Take a Pill.

Updated for typos!
In Sunday's New York Times there was an interesting article by Dr. Julie Holland about how women's emotions should be appreciated and not pathologized.  

First, let me tell you that I read Dr. Holland's book called Weekends at Bellevue and I hated it.  She talked about her sadistic feelings (and sometimes actions) towards patients, and her own therapy to overcome this.  While I realize that we don't all harbor the kindest feelings towards every single patient on every single day, and sometimes docs have rough stuff going on too, I was appalled.  She whistled some song about here comes the parade when prisoners were brought into the ER.  She was mean and disrespectful.  Feelings are feelings, but to knowingly be sadistic and disrespectful to patients is inexcusable. I read it and was embarrassed to be a member of her profession. 

Now that I got that off my chest, the article in Sunday's NY Times called Medicating Women's Feelings was interesting and thought-provoking.  Holland writes:

WOMEN are moody. By evolutionary design, we are hard-wired to be sensitive to our environments, empathic to our children’s needs and intuitive of our partners’ intentions. This is basic to our survival and that of our offspring. Some research suggests that women are often better at articulating their feelings than men because as the female brain develops, more capacity is reserved for language, memory, hearing and observing emotions in others.

These are observations rooted in biology, not intended to mesh with any kind of pro- or anti-feminist ideology. But they do have social implications. Women’s emotionality is a sign of health, not disease; it is a source of power. But we are under constant pressure to restrain our emotional lives. We have been taught to apologize for our tears, to suppress our anger and to fear being called hysterical.

Dr. Jeff Lieberman, the past APA president tweeted that the article was 'anti-psychiatry.' I didn't see it that way at all.  Holland talks about how anti-depressants clearly help some people, but she also discusses the high numbers of women who are treated with them.  It's an issue we've  discussed many times here on Shrink Rap:  our illnesses are syndromic, they are decided by committees (with the help of research), but they can be inexact.  Say you need 5 symptoms for 2 weeks to meet criteria for depression, and a patient comes in with only 3 symptoms for 10 days, but those three symptoms include profound sadness, suicidal thoughts, and a loss of appetite, I don't believe too many psychiatrists are going to stand there with a check-list saying, nope, you need 4 more days and 2 more symptoms before we can call it depression, come back then.  

Was the article right?  Was it just plain sexist?  Are women moodier than men and is treating this a form of suppression?  I am certainly moodier than my husband.  But everyone I  know is moodier than ClinkShrink and she's a woman.  Should we accept and celebrate, depression in women, but not in men?  Are some people over -diagnosed and over- medicated? Who is to be the  judge of that if a patient says 'Look, this medicine helps me feel better'?  Or are there people who are under-diagnosed and under-medicated?  I suspect the answer is 'All of the Above,' and I still go with the idea that if you show up at my door and say you're suffering, and you want to try meds, I'm usually fine with that. But before you knock, know that I will also insist on therapy, at least at the beginning of treatment.

So I think questioning is fine.  What is the role of the pharmaceutical companies in deciding what's an illness and what we treat?  Do we under-diagnose or over-diagnose?   
Emotions occur along a spectrum and they come and go over days or hours if not weeks or months.  It's not anti-psychiatry to be skeptical or to question.  And debilitating mental illness is not subtle. I do believe it's the subtleties, the symptoms that come and go in someone functioning normally that Holland may be talking about.  

What do you think?